ANNALS OF MEDICINE braIn, causing irreversible brain damage. The most troubling finding, however, was that only a third of the trauma cen- ters surveyed said that they routinely monitored ICP at all. In another hospi- tal, the surge in Urgent Four's ICP on Tuesday night which signalled the for- mation of a blood clot might not have been caught. Such dramatic variations in medical practice are hardly confined to neurosur- gery. It is not unusual for doctors in one community to perform hysterectomies, say, at two or three times the rate of doc- tors in another town. Rates for some cardiac procedures differ around the country by as much as fifty per cent. Ob- stetrical specialists are almost twice as likely to deliver children by cesarean sec- tion as family physicians are. In one clas- sic study published seven years ago, a team of researchers found that children in Boston were 3.8 times as likely to be hospi talized for asthma as children in Rochester, New York; 6.1 times as likely to be hospitalized for accidental poison- ing; and 2.6 times as likely to be hospi- talized for head injury. In most cases, however, the concern about practice variatIon has focussed on the issue of cost. The point of the Boston - Rochester study was not that the children of Boston were receiving con- siderably better care than their counter- parts in upstate N ew York but, rather, that health care for children in Boston might well be needlessly expensive. When it comes' to brain injury, the stakes are a little higher. At the handful of centers around the country specializing in brain trauma, it is now not un- usual for the mortality rates of coma pa- tients to run in the range of twenty per cent or less. At trauma centers where brain injury is not a specialty, mortality rates for coma patients are often twice that. "If I break my leg, I don't care where I go," Randall Chesnut, a trauma specialist at San Francisco General Hos- pital, told me. "But, if I hit my head, I want to choose my hospital." Part of the problem is that in the field of neurosurgery it has been difficult to reach hard, scientific conclusions about procedures and treatments. Physicians in the field have long assumed, for example, that blood clots in the brain should be re- moved as soon as possible. But how could that assumption ever be scientifically verified? Who would ever agree to let a comatose family member lie still with a mass of congealed blood in the brain while a team of curious researchers watched to see what happened? The compleXlty and mystery of the brain has, moreover, led to a culture that rewards intuition, and has thus convinced each neurosurgeon that his own experience is as valid as anyone else's. Worse, brain in- jury is an area that is of no more than passing interest to many neurosurgeons Most neurosurgeons make their living doing disk surgery and removing brain tu- mors. Trauma is an afterthought. It doesn't pay particularly well, because many car-accident and shooting victims don't have insurance. (Urgent Four her- self was without insurance, and a public collection has been made to help defray her medical expenses.) Nor does it pose the kind of surgical challenge that, say, an d " I ' aneurysm or a tumor oes. t s some- thing like--well, you've got mashed-up brains, and someone got hit by a car, and it's not really very interesting," G hajar says. "But brain tumors are kind of inter- esting. What's happening with the DNA? Why does a tumor develop?" Then, there are the hours, long and unpredictable, tied to the rhythms of street thugs and drunk drivers. GhaJar, for example, routinely works through the night. He practices primarily out of Jamaica Hos- pital, not the far more presti- gious New York Hospital, be- cause Jamaica gets serious brain-trauma cases every sec- ond day and New York might get one only every second week. "If I were operating and - doing disks and brain tumors, 1'd be making ten times as much," he says. In the entire country, there are probably no more than two dozen neurosurgeons who, like Ghajar, exclusively focus on re- searching and treating brain trauma. Ghajar says that in talking to other neurosurgeons he sensed a certain resig- nation in treating brain injury-a feeling that the prognosis facing coma patients was so poor that the neurosurgeon's role was limited "It wasn't that the neuro- surgeons were lazy," Ghajar said. "It was just that there was so much information out there that it was confusing. When they got young people in comas, half of the patients would die. And the half that lived would be severely disabled, so 39 "The best travel clothing in the world" J long-lasting, smart-looking, ,. easy-care; pickpocket-proof travel clothing. Fast-drying, comfortable travel underwear; Tilley Hats. . . HA . CLASSIC SHORTS GUARANTEED fOR un Free 48-page catalogue In San Francisco: The Hound In Burlingame, CA: Malouf's. 1-800-884-7072 In Clifton, NJ: Rowe-Manse 300 LANGNER ROAD WEST SENECA NY p" . . '1; '"oW y ., \ :'- þ"'- . . . . . '. If You Have Diabetes . . . Our internationally acclaimed program will show you how to live a more enjoyable life · 4 days of intensive outpatient treatment · Group and individual education · National and international attendees · Follow-up at our Harvard affiliated center in Boston or at JoslIn Centers nationwide Call: 1-800- 2HALT-DM _ Joslin Diabetes Center M,,^Ä:::.R:t 11,/\' S, .b. .... P"" . V ;,:: ':;E:Y^.',. ::.P.: . . .. . l ' 1?liÀèÇ e YJ fId ..' f :E."L.,:B"P ."H\O::N:;:e" ::,&:u.:o.. - 3'56 '" 3"3:::::2:'.'2 LONDON FLATS personally selected by EARNUM CHRIS J 800-366-2048 · 423-652-2048 f....' :- . .., ::,,' \a .:!. ,....',' , , .. l'-- '"' "' I "- .. ,,' .J , ,\\ .,;. .) \\ r , , ... , '-. LET THE lIAND DO THE TALKING 't'þ.p An object of beauty, It's the artIst's model, objet 't d'art, subtle commumcator, whimsical gIft. Hand U crafted of precIOUS wood Choose left or nght 10" Artist's Model Hand $39.95 (+4.95 S&H) f B ochu e or ?rder: T DÅ í'lING S J'ORIES 1 800 895 3050 J., _ ___ d THOUGHTFUL GIFTS NEED A STeRY COUNTRY WALKERS W oRLðwlðe WaLklnç Vacanons + Small groups + Expert gUldes + Fine hotels and cuisine + Actwe, educatwnal itmerarzes Call for a catalog 800-464-9255 PO Box lS0NY. WaterburvVermom 05676